Lead Poisoning-Associated Death from Asian Indian Folk
Remedies -- Florida

In January 1984, a 9-month-old Asian Indian boy died in Florida
of
lead poisoning that resulted from ingestion of folk remedies. The
case report follows.

The infant, born in April 1983 in Massachusetts, moved with his
family to Lake County, Florida, when he was 6 months old. He was
under the care of a local physician and developed normally until he
was 8 months old. In December 1983, he became lethargic and less
responsive and stopped crawling. Within a few weeks, the
behavioral
abnormalities worsened, and he refused bottle-feeding, and began to
have tremors. On January 5, 1984, the infant was examined by a
physician for an ear infection, and the behavioral changes were
noted. On January 9, the infant had seizures at his home and was
taken to the hospital emergency room. During a lumbar puncture, he
became apneic and was transferred to another hospital. The lumbar
puncture ruled out meningitis as the cause of his neurologic signs.
A
computerized tomography scan suggested a midline cerebellar mass
with
enlargements of the third and lateral ventricles in the brain. On
January 10, he underwent an operation for decompression of the
posterior fossa. During the operation, apparent necrotic tissue
was
excised from the cerebellum. The infant died the next day.

Postmortem examination revealed severe lead poisoning as the
underlying cause of death. High concentrations of lead were found
in
the blood, urine, liver, and kidneys (Table 4). Lead lines were
seen
in radiographs of the long bones.

The source of lead could not be identified in the house or
environment on examination. However, the parents disclosed that
they
had regularly given the baby folk remedies from India since he was
2
months old. The parents provided samples of three folk remedies
for
analysis by the Florida Department of Health and Rehabilitative
Services. All three contained lead (Table 5). The highest
concentration (1.6%) was in ghasard, a brown powder given once
daily
as a tonic.
Reported by ML Colgrove, M Zinion, Nursing Dept, JM Atkinson, MD,
Lake
County Public Health Unit, Tavares, T Collins, MD, District 3,
Gainesville, L Maslund, MW Clark, MD, WF Hamilton, MD, Office of
the
Medical Examiner, District 8, Gainesville, NP Chopra, MD, Lake
County,
CL Bush, Office of Laboratory Svcs, JJ Witte, MD, JJ Sacks, MD,
Acting
State Epidemiologist, Florida Dept of Health and Rehabilitative
Svcs;
Div of Field Svcs, Epidemiology Program Office, Special Studies Br,
Chronic Diseases Div, Center for Environmental Health, CDC.

Editorial Note

Editorial Note: Lead poisoning should be suspected in every infant
and child with developmental problems, behavioral abnormalities, or
neurologic symptoms. Signs of acute lead encephalopathy include
coma,
seizures, bizarre behavior, ataxia, apathy, incoordination,
vomiting,
alteration in consciousness, and subtle loss of recently acquired
skills (1). Lead encephalopathy is a medical emergency and
requires
prompt diagnosis and treatment. One or more of the above signs and
a
blood-lead concentration of 70 ug/dl or higher are sufficient for
diagnosis. Lumbar puncture is usually not required for diagnosis
of
acute lead encephalopathy and may pose a risk to the patient when
intracranial pressure is elevated. Treatment consists of chelation
with 2,3-dimercaptopropanol (BAL--British anti-lewisite) and
edathamil
calcium disodium (CaNa((2))-EDTA) (1).

At blood-lead concentrations of 50 ug/dl or higher, lead
poisoning
can produce the following symptoms: decreased play activity,
lethargy,
anorexia, sporadic vomiting, intermittent abdominal pain, and
constipation. Children with lead poisoning should be treated on an
emergency basis, since they may develop acute encephalopathy (1).

Lead-containing folk remedies have been reported as the cause
of
lead poisoning in Mexican-Hispanic and Hmong children (2-4). This
report of lead-containing folk remedies from India raises the
concern
that lead may be present in folk remedies from other parts of the
world. Hmong folk remedies have also been found to contain arsenic
and
mercury (4), and they have been suspected of causing arsenic
poisoning
in several adults (5). Other heavy metals, therefore, may also be
present in some Indian folk remedies.

Health-care providers need to be sensitive to the cultural
beliefs
and practices of ethnic groups. In their native countries, these
groups may have used traditional foods and remedies. Parents often
give these substances to their infants and children to help their
growth and development or to treat them for minor illnesses.
Often,
the parents acquire the substances from relatives and friends, and
they do not suspect the substances may be harmful. If symptoms
persist, they may give even larger amounts, inadvertently causing
further illness.

Testing for lead toxicity can be done simply and relatively
inexpensively by determining blood concentrations of lead and
erythrocyte protoporphyrin (EP). Determining the EP level is a
good
screening test for lead exposure, since an elevated EP level
usually
indicates iron deficiency or lead toxicity (6). If lead poisoning
is
suspected, however, both EP and blood-lead levels should be
determined
without delay.

Lead poisoning can be prevented by removing the child from
exposure to lead. In the United States, the most common source of
lead that causes symptomatic poisoning is deteriorating lead-based
paint in older houses. Other potential sources--including
occupations
and hobbies that result in exposure to lead; food stored in
imported,
glazed pottery; and folk remedies--should also be investigated. It
is
very important that the source or sources of lead be identified and
removed from the child's environment.

Based on recommendations by CDC's Ad Hoc Advisory Committee on
Childhood Lead Poisoning Prevention, CDC is revising the guidelines
for lead screening in young children. The new guidelines recommend
EP
screening of all children between 9 months and 6 years of age. A
child with an EP level of 35 ug/dl or higher should have a repeat
EP
test, a blood-lead test, and a hematocrit or hemoglobin test. Lead
toxicity--defined as a blood-lead level of 25 ug/dl or higher,
along
with an EP level of 35 ug/dl or higher--requires further medical
evaluation and environmental investigation to identify the
source(s)
of lead. These new guidelines will be distributed in the form of a
CDC statement to health departments and health-care providers.
More
details will be included in a future issue of MMWR.

CDC. Preventing lead poisoning in young children: a statement
by
the Center for Disease Control. Atlanta, Georgia: Center for
Disease Control, 1978.

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